Organic causes of dyspepsia, and discriminating functional from organic dyspepsia

[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]

The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources. This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).

[Managing of the patient with dyspepsia. Clinical Practice Guideline. Update 2012]

The "Preparation of Clinical Practice Guidelines in Digestive Diseases, from Primary Care to Specialist Care" Program, is a joint project by the Spanish Gastroenterology Association (AEG), the Spanish Society of Family and Community Medicine (SEMFyC), and the IberoAmerican Cochrane Center (CCI). We present the update of the Guidelines on the Management of Dyspepsia, which was published in 2003. The essential criteria provided in the AGREE (Appraisal of Guidelines, Research and Evaluation for Europe) Instrument were taken into account in the preparation of this document. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to classify the scientific evidence and strengthen the recommendations.

Prospective 6 weeks follow-up post-cholecystectomy: the predictive value of pre-operative symptoms

OBJECTIVE

Many patients with symptomatic cholelithiasis report persisting symptoms after elective cholecystectomy. The current prospective follow-up study aims at the identification and valuation of risk factors for negative symptomatic outcome at 6 weeks.

METHODS

Consecutive patients (n = 183), age 18-65 years, indicated for elective cholecystectomy due to symptomatic cholelithiasis, completed a self-report questionnaire. At 6 weeks post-operatively, the same self-report questionnaires were completed (n = 129). Predictors of the persistence and emergence of biliary and dyspeptic symptoms at 6 weeks post-cholecystectomy were investigated using univariate and multivariate logistic regression.

RESULTS

At 6 weeks post-operatively, the report of post-operative biliary symptoms was independently predicted by pre-operative dyspeptic symptoms (OR = 6.60) and bad taste (OR = 3.55). Pre-operative flatulence was an independent predictor of the report of biliary and dyspeptic symptoms ((OR = 3.33) and (OR = 3.27), respectively) and persisting biliary symptoms (OR = 4.21). Predictors of symptomatic outcome were only identified in women, not in men.

CONCLUSION

Patients with pre-operative dyspeptic symptoms, notably bad taste and flatulence, have an increased risk of negative post-cholecystectomy outcomes at 6 weeks. A symptom-specific approach should lead to optimalization of the indication of cholecystectomy and information of patients. Known risk factors for long-term outcomes might be valuable in female patients only.

Models of gastric hyperalgesia in the rat

Despite the prevalence of dyspepsia, nonhuman models for study of gastric hyperalgesia are limited. We thus characterized responses to gastric distension (GD) in the absence of and after two different gastric insults. A balloon was surgically placed into the stomach, and electromyographic responses to GD were recorded from the acromiotrapezius muscle at various times after balloon placement. Rats received either 20% acetic acid (HAc) or saline injections into the stomach wall or 0.1% iodoacetamide (IA) in drinking water. Responses to GD were monotonic with increasing distending pressure (10-80 mmHg) and were reproducible from days 3-14 after balloon implantation. Both HAc injection and IA ingestion led to increased responses to GD (i.e., gastric hyperalgesia), which, in the case of HAc, persisted for 60 days after HAc treatment. HAc injection produced ulcers in all treated animals; IA ingestion produced no lesions. Myeloperoxidase activity significantly increased after HAc but not saline injection or IA ingestion. In the awake, unrestrained rat, visceromotor responses to GD are quantifiable, reliable, and reproducible. Significantly enhanced responses to GD were apparent in two models of gastric insult, both of which may be useful for the study of the mechanisms of gastric hyperalgesia.

Dose finding study of mosapride in functional dyspepsia: a placebo-controlled, randomized study

BACKGROUND

Prokinetic agents have shown variable efficacy in the treatment of functional dyspepsia. Mosapride is a new prokinetic 5-hydroxytryptamine-4 agonistic agent.

AIM

To evaluate the efficacy of three dosage regimens of mosapride compared with placebo in the treatment of functional dyspepsia.

METHODS

Patients were randomly allocated to treatment with placebo or mosapride (5 mg b.d., 10 mg b.d. or 7.5 mg t.d.s.) in a double-blind, prospective, multicentre, multinational study. The change in symptom severity score from an untreated baseline week to the sixth week of treatment was used to compare treatment efficacy.

RESULTS

There were 141, 140, 143 and 142 patients valid for evaluation in the intention-to-treat population in the placebo, mosapride 5 mg b.d., mosapride 10 mg b.d. and mosapride 7.5 mg t.d.s. groups, respectively. The mean changes in the overall dyspeptic symptom score were - 0.90, - 0.94, - 0.88 and - 0.89, respectively, and the proportions of patients feeling better at the end of the treatment period were 60%, 59%, 59% and 61%, respectively. No statistically significant difference was seen.

CONCLUSIONS

Treatment of functional dyspepsia with mosapride was not superior to placebo. The result raises the question of whether treatment with prokinetic agents is appropriate for functional dyspepsia.